Utility Member filing report:

Date of damage to underground facility (m/d/y):

City & County where damaged occurred:

Address where damage occurred:

Right of Way where damage occurred: No Response Data Not Collected Dedicated Public Utility Easement Federal Land Pipeline Power Transmission Line Private (Business) Private Easement Private (Landowner) Public (City Street) Public (County Rd) Public (Interstate Hwy) Public (Other) Public (State Hwy) Railroad Unknown / Other

Who damaged the facility?

Did they have a locate number (Y or N)?

If yes, give the locate (ticket) number:

Type of Excavation Equipment: No Response Auger Backhoe / Trackhoe Boring Data Not Collected Drilling Directional Drilling Explosives Grader / Scraper Hand Tools Vacuum Equipment Probing Device Trencher Unknown / Other

Type of work performed: No Response Agriculture Blading Bldg Construction Bldg Demolition Cable TV Curb / Sidewalk Data Not Collected Drainage Driveway Electric Engineering / Surveying Fencing Gas Irrigation Landscaping Lot Grading Petroleum Pipeline Pole Public Transit Authority Railroad Maint Road Work Sewer Site Development Steam Storm Drain / Culvert Street Light Telecommunications Traffic Signal Transmission Pipeline Water Waterway Improvement Unknown / Other

Were the underground facilities located (Y or N)?

If yes, were they properly located (Y or N)?

What type of utility was affected? Select all that apply:

  Cable TV Electric Gas Telephone Wastewater Water Other

(If other, please note):

Estimated cost of damage / repair?

  Under $500 $500 - $1,000 $1,000 - $2,500 Over $2,500

Did the damage cause an interruption of service (Y or N)?

How many customers were affected by the outage (appx)?

If the occurrence was a "near miss", please check here:

(A near miss is considered to be "no damage to the utility, but work was performed on the easement or facility without authorization, with no financial damage".)